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“Acute scrotum” in Henoch-schönlein syndrome
“ACUTE SCROTUM” IN HENOCH-SCHONLEIN SYNDROME J. E. W. CROSSE, D. W. SODERDAHL, D. T. SCHAMBER,
M.D. M.D. M.D.
From the Urology Service, Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii
ABSTRACT - Two patients with Henoch-SchGnlein syndrome presented with clinical pictures mimicking testicular torsion. No evidence of testicular torsion was found. A review of the literature revealed that testis torsion is very rarely associated with testicular involvement in Henoch-Schblein sundrome. and hence onlu rarelu is surgical exvloration reauired. Y
Y
Y
The differential diagnosis of an acute, painful intrascrotal swelling in childhood includes strangulated inguinal hernia, torsion of testis, torsion of appendix testis-epididymis, epididymitisorchitis, and trauma. Because of the imprecision of noninvasive diagnostic methods, surgical exploration generally is indicated. Recent reports and personal experience with the “acute scrotum” in Henoch-Schonlein syndrome support a nonoperative approach in these patients. Case Reports Case 1 A four-year-old white male was seen with a one-week history of fever, migratory arthralgia, and purpuric lesions of the back, lower extremities, and genitalia. Two days after admission sudden swelling, pain, and tenderness of the left hemiscrotum and its contents developed. Analysis and culture of the urine, and complete blood count were normal. Rather than risk the sequelae of untreated torsion of the testis, especially in view of the brief duration of symptoms, transscrotal exploration was undertaken. A markedly edematous scrotal wall and numerous petechial-purpuric lesions of the epididymis and testis were found. There was no torsion. Complete resolution of genital symptoms occurred in four days during which time prednisone (2 mg.
66
per kilogram per day) was administered. Physical examination one month later was completely normal.
Case 2 A six-year-old white male had swelling, and pain and tenderness of the left hemiscrotum and its contents for ten hours. Less than one day prior he had been discharged after evaluation and observation for Henoch-Schonlein syndrome. The scrotum was edematous and purpuric. The left intrascrotal contents were indeterminate, and the spermatic cord was thickened. Urinalysis, urine culture, and complete blood count were normal. Because of the long delay between onset of symptoms and treatment, observation alone was elected. Symptoms and findings resolved spontaneously within two days. Physical examination one month later was completely normal. Comment Henoch-Schonlein syndrome is a diffuse vasculitis which may involve a number of organ systems. Classically, Henoch-Schonlein syndrome includes nonthrombocytopenic purpura, arthralgia, abdominal pain, and abnormalities of the urinary sediment similar to those in poststreptococcal glomerulonephritis. The sequence and
UROLOGY
/ JANUARY 1976 / VOLUME
VII,
NUMBER
1
severity of these manifestations are highly variable. Boys are affected more frequently than girls, with a Desk age incidence between four and five years. LCause” is unknown, although an immunologic basis is suspected. Laboratory studies are not diagnostic. Therapy is essentially supportive, although steroids are reported to produce dramatic alleviation of some symptoms (abdominal discomfort and joint pain) and some signs (scalp and facial edema). Eadie and Higgins’ first drew attention to an uncommon feature of Henoch-SchGnlein syndrome, the “acute scrotum” mimicking testicular torsion. Including our 2 patients 14 cases of Henoch-SchGnlein syndrome concomitant with the “acute scrotum” have been describede2-’ Of 9 patients explored surgically, only one demonstrated torsion of the testis. The others disclosed edema and petechial-purpuric lesions of scrotum, testis, epididymis, and spermatic cord to variable degrees. All cases resolved to apparent normalcy. Several patients received steroids without clearly beneficial effects. We conclude that the “acute scrotum” of Henoch-Schbnlein syndrome is an uncommon manifestation of the underlying condition and not an unrelated incident. It would appear that in Henoch-Schiinlein syndrome, in the absence of
UROLOGY
/
JANUARY 1976 /
VOLUME VII, NUMBER 1
strong evidence for strangulated inguinal or testicular torsion, surgical exploration necessary.
hernia is not
Urology Service Martin Army Hospital Fort Benning, Georgia 31905 (DR. CROSSE) References
1,
EADIE, D. G. A., and HIGGINS, P. M.: Apparent torsion of the testicle in a case of Henoch-Schijnlein purpura, Br. J. Surg. 51: 634 (1964). complication of 2. FITZSIMMONS, J. S.: Uncommon anaphylactoid purpura, Br. Med. J. 4: 431 (1968). NOUSSIAS, M., BLANDY, A. C., and WARD-MCQUAID, 3’ N. : lntussusception in Henoch-SchGnlein purpura: a report of two cases requiring operation, Br. J. Surg. 56: 503 (1969). in chil4. HAAR, J., and SPARREVOHN, S.: Epididymitis dren: a brief report together with reports of six cases, Acta Paediatr. Stand. 60: 216 (1971). 5 SAHN, D. O., and SWARTZ, A. D.: Schiinlein-Henoch ’ syndrome: observations on some atypical clinical presentations, Pediatrics 49: 614 (1972). 6. LOH, H. S., and JALAN, 0. M.: Testicular torsion in syndrome, Br. Med. J. 2: 96 (1974). 7, Henoch-SchGnlein LABRUNE, B., and VIGNES, B.: Unusual manifestations of Henoch-Schbnlein purpura - localization in the testis and neurological disturbances, Nouv. Presse Med. 3: 1023 (1974).
67
M.D. M.D. M.D.
From the Urology Service, Department of Surgery, Tripler Army Medical Center, Honolulu, Hawaii
ABSTRACT - Two patients with Henoch-SchGnlein syndrome presented with clinical pictures mimicking testicular torsion. No evidence of testicular torsion was found. A review of the literature revealed that testis torsion is very rarely associated with testicular involvement in Henoch-Schblein sundrome. and hence onlu rarelu is surgical exvloration reauired. Y
Y
Y
The differential diagnosis of an acute, painful intrascrotal swelling in childhood includes strangulated inguinal hernia, torsion of testis, torsion of appendix testis-epididymis, epididymitisorchitis, and trauma. Because of the imprecision of noninvasive diagnostic methods, surgical exploration generally is indicated. Recent reports and personal experience with the “acute scrotum” in Henoch-Schonlein syndrome support a nonoperative approach in these patients. Case Reports Case 1 A four-year-old white male was seen with a one-week history of fever, migratory arthralgia, and purpuric lesions of the back, lower extremities, and genitalia. Two days after admission sudden swelling, pain, and tenderness of the left hemiscrotum and its contents developed. Analysis and culture of the urine, and complete blood count were normal. Rather than risk the sequelae of untreated torsion of the testis, especially in view of the brief duration of symptoms, transscrotal exploration was undertaken. A markedly edematous scrotal wall and numerous petechial-purpuric lesions of the epididymis and testis were found. There was no torsion. Complete resolution of genital symptoms occurred in four days during which time prednisone (2 mg.
66
per kilogram per day) was administered. Physical examination one month later was completely normal.
Case 2 A six-year-old white male had swelling, and pain and tenderness of the left hemiscrotum and its contents for ten hours. Less than one day prior he had been discharged after evaluation and observation for Henoch-Schonlein syndrome. The scrotum was edematous and purpuric. The left intrascrotal contents were indeterminate, and the spermatic cord was thickened. Urinalysis, urine culture, and complete blood count were normal. Because of the long delay between onset of symptoms and treatment, observation alone was elected. Symptoms and findings resolved spontaneously within two days. Physical examination one month later was completely normal. Comment Henoch-Schonlein syndrome is a diffuse vasculitis which may involve a number of organ systems. Classically, Henoch-Schonlein syndrome includes nonthrombocytopenic purpura, arthralgia, abdominal pain, and abnormalities of the urinary sediment similar to those in poststreptococcal glomerulonephritis. The sequence and
UROLOGY
/ JANUARY 1976 / VOLUME
VII,
NUMBER
1
severity of these manifestations are highly variable. Boys are affected more frequently than girls, with a Desk age incidence between four and five years. LCause” is unknown, although an immunologic basis is suspected. Laboratory studies are not diagnostic. Therapy is essentially supportive, although steroids are reported to produce dramatic alleviation of some symptoms (abdominal discomfort and joint pain) and some signs (scalp and facial edema). Eadie and Higgins’ first drew attention to an uncommon feature of Henoch-SchGnlein syndrome, the “acute scrotum” mimicking testicular torsion. Including our 2 patients 14 cases of Henoch-SchGnlein syndrome concomitant with the “acute scrotum” have been describede2-’ Of 9 patients explored surgically, only one demonstrated torsion of the testis. The others disclosed edema and petechial-purpuric lesions of scrotum, testis, epididymis, and spermatic cord to variable degrees. All cases resolved to apparent normalcy. Several patients received steroids without clearly beneficial effects. We conclude that the “acute scrotum” of Henoch-Schbnlein syndrome is an uncommon manifestation of the underlying condition and not an unrelated incident. It would appear that in Henoch-Schiinlein syndrome, in the absence of
UROLOGY
/
JANUARY 1976 /
VOLUME VII, NUMBER 1
strong evidence for strangulated inguinal or testicular torsion, surgical exploration necessary.
hernia is not
Urology Service Martin Army Hospital Fort Benning, Georgia 31905 (DR. CROSSE) References
1,
EADIE, D. G. A., and HIGGINS, P. M.: Apparent torsion of the testicle in a case of Henoch-Schijnlein purpura, Br. J. Surg. 51: 634 (1964). complication of 2. FITZSIMMONS, J. S.: Uncommon anaphylactoid purpura, Br. Med. J. 4: 431 (1968). NOUSSIAS, M., BLANDY, A. C., and WARD-MCQUAID, 3’ N. : lntussusception in Henoch-SchGnlein purpura: a report of two cases requiring operation, Br. J. Surg. 56: 503 (1969). in chil4. HAAR, J., and SPARREVOHN, S.: Epididymitis dren: a brief report together with reports of six cases, Acta Paediatr. Stand. 60: 216 (1971). 5 SAHN, D. O., and SWARTZ, A. D.: Schiinlein-Henoch ’ syndrome: observations on some atypical clinical presentations, Pediatrics 49: 614 (1972). 6. LOH, H. S., and JALAN, 0. M.: Testicular torsion in syndrome, Br. Med. J. 2: 96 (1974). 7, Henoch-SchGnlein LABRUNE, B., and VIGNES, B.: Unusual manifestations of Henoch-Schbnlein purpura - localization in the testis and neurological disturbances, Nouv. Presse Med. 3: 1023 (1974).
67